Avoidable vs. Unavoidable Pressure Injuries

Dot Weir, RN, CWON, CWS

Holland, Michigan, USA

Unavoidable Pressure Injuries

• An unavoidable pressure ulcer can develop even though the provider:
• Evaluated the individual's clinical condition and pressure ulcer risk factors;
• Defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice
• Monitored and evaluated the impact of the interventions
• Revised the approaches as appropriate

Schmitt, S et al. WOCN Society Position Paper: Avoidable Versus Unavoidable Pressure Ulcers/Injuries. Journal of Wound, Ostomy and Continence Nursing 44(5):p 458-468, September/October 2017

Avoidable Pressure Injuries

All of that didn’t happen

A Case

• 61-year-old male, Currently residing in rehab facility
• PMH: CAD with MI, S/P Stent placement, hypertension
• History of dementia; CVA after stent placement, episodic confusion with aggressive behavior, recent weight loss, 35 pack year history of smoking
• Sent to ED for hematuria and increasing confusion
• On admission Hgb 8.2, WBC 16.2, the following day Hgb 5.4
• Anticoagulated due to stent; held due to bleeding
• Bruising to feet, back and buttocks
• Pulses non-palpable, monophasic doppler, prolonged capillary refill time

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Skin

• Ecchymotic areas toes, mid-back and buttocks on admission
• 2 RN confirmation skin check on admission
• Care plan appropriate
• Documented turning approximately every two hours with few misses, also well documented bathing and cleansing
• From admission was placed on high specification foam with reactive turning and positioning device (Tortoise)

Hospital course

• Received RBCs X2, catheter inserted under anesthesia, began continuous bladder irrigation
• Negative test for COVID
• Consults with dietician, physical and occupational therapy
• Had to apply mittens to prevent pulling out catheter, IV
• Hospital provided 1:1 sitter
• Bleeding resolved
• Day 4 discharged back to Rehab facility with foley catheter

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Hospital course cont.

• Three days later readmitted with fever 103.4 rectally
• Diagnosis: Urosepsis
• Now tested positive for COVID, and continued to test positive every 3-4 days for the next 21 days
• Continued with similar care plan and turning schedule as previously described
• Again on high specification foam with reactive turning and positioning device (Tortoise)
• Began losing weight
• Consults with dietician, physical and occupational therapy day 2
• Hit or miss eating, did well at first with supplement then, refused PT more often than agreed, often thrashed out at those trying to help him move
• Had Tele-sitter

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Over the following 4 weeks�

• Was on routine and prn antianxiety medications
• Mental status continued to deteriorate
• Often striking out at nurses and therapists
• Refusing medications
• He pulled out his foley catheter; attempted condom catheter, he pulled those off also (when mitts removed)
• Adequately emptying bladder per bladder scans
• Used briefs and incontinence skin protection
• Continued to spike high fevers; placed on cooling blanket prn
• Weight stabilized but continued to refuse food although would drink supplements
• Continued to test Covid positive

Five weeks into hospitalization

• Continued spiking high fevers
• Placed on cooling blanket prn
• Developed pneumonia with congested cough
• Feared to be aspirational
• Desaturating to 80’s, placed on NC oxygen
• Erratic behavior continued
• Heart rate with runs of tachycardia, elevated MAP

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Skin issue noted

• 5.5 weeks in hospital, had rapid onset of skin issue
• Care plan immediately changed
• Dobhoff tube placed
• Placed on Dolphin bed
• Wound care consulted
• Began local wound care
• 3 days later, had cardiac arrest and expired

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What do YOU think?

• Was this pressure injury avoidable or unavoidable

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• Was this an example of skin failure?

Thank You!